2010-08-01

Hi …….!

Here are my comments to your "conservative" friend. Remember that I am writing as a

Swedish conservative politician - active member of the leading party in the present governing
coalition since 2006. We won that position after the social democrats had held the political
majority at the national level in 65 of the previous 72 years. Btw, ……, I am still a US
citizen, not a Swedish citizen. Non-Swedish citizens can vote and hold office here at the local
and county level. Health care in Sweden is primarily a county responsibility, but a municipal
responsibility for in-home care of the elderly and functionally disadvantaged. The national
government is involved, of course, but the systems are primarily funded by county and
municipal taxation.

Clearly we Swedish "conservatives" are constantly reforming our health system, but in no
way revolutionizating (a word?) the basic fundamentals. We are making pragmatic changes
that lead to more free choice, encouraging even more "private" actors to become operatives in
the one-payer system, streamlining the health care bureaucracy, and investing heavily in IT
support - all cost effectiveness measures. We are also in the process of privatizing the medical
drug distribution system. In our one payer system (everyone is free to buy additional
complementary insurance or choose to pay totally from their own pocket for totally "private"
health care –yes, we do have totally "private" hospitals which also work on contract for the
public system) all pay about 10% of their taxable income to the "public" system which
provides over (I'm guessing a bit) 95% of the country's health care. In other words, we have
a pay according to your ability system that most Americans might call socialistic. An
individual here pays above that 10% tax rate, a maximum of $250. per year on drugs and $15.
per doctor visit. Our dental system is not a part of what I describe here. It has its own
insurance system.

Hope you don't mind if I share all this with some political colleagues even more directly
involved in health care management than I. My area of political responsibility is with the
school systems.

Now to the specific comments to your friend (my comments in italics)

Subject: Re: Health Care Comment from Swedish friend

Sweden's health care system offers two lessons for the policymakers of the United States.
The first is that a single-payer system is not the answer to the problems faced as
Americans. Sweden's system does not hold down costs and results in rationing of care.

Hopefully we have more than 2 lessons for the US policymakers. However, of course, each
nation must find its own solutions based on its own experiences.

Obviously I think the single-payer system with complementary private plans is the right way
for the US to go - efficient and predictable revenue intake. Holding costs down is then a
function of the political system that is accountable to the people at the election booth and
between elections by intensive debate - and with health care being always a primary interest f
the voter, the politicians should be under real pressure to deliver cost effective service - much
more so that totally private actors, I would argue, where the pressure is and perhaps should
be always on for higher and higher salaries-bonuses-profits. An American conservative
argues that holds costs down. A Swedish conservative says "not necessarily" .

Certainly the Swedish system of central medical drug purchasing and freer use of generics is
holding those costs in check. Remember we are paying only about 9% of GNP to the system,
half of what the USA is paying. Yes, you could call the Swedish health system as a rationing
system, but so is the American in which private insurance companies and employers are
managing the rationing. I would suggest the Swedish system, therefore, has more
accountability built in, to say the least.

The second lesson is that market-oriented reforms must permit the market to work.
Specifically, government should not protect health care providers that fail to provide
patients with a quality service from going out of business.

A Swedish conservative has no trouble with this. And even a lot of the modern social
democrats would have no problem with that. A number of "more market oriented reforms"
have in fact been put in place by the earlier social democratic majority governments. Since
the Swedish system more and more is putting health care providers (including the government
run providers) into competitive bidding, we are strengthening the positives of the so called
"market" while we try to diminish the negatives.

And while on the "market" issue, I would like to make one more point. Health care in my
world can never be an "insurance" issue. Something like 70-80% of all medical costs occur
in the last 2-3 years of our lives.... a very predictable event. Insurance is for unpredictable
occurrences where a collective of payers share the risk for the unpredictable. To me health
care is a fundamental social right, managed as such and paid for by all more or less
according to their ability to pay. To me that is pragmatism, not socialism or any other "ism"
that conjures up a lot of "hot" feelings among people.

Researchers studying Swedes waiting for hip or knee replacement concluded that
"almost every aspect of daily life is affected by the indeterminate wait for surgery and
the related experiences of pain and disability.

We now have a 3-month care guarantee in place which means if that or any other
operation/treatment is not underway, the patient can go to another county where their care
capacity might be more for just that treatment/operation and could thus treat quickly. The
"home" county then pays the treating country for the procedures. There are a number of
other reforms that have reduced the "popularity" of clinics to run "wait lists" - so popular
during the social democratic years - that also use more market oriented mechanisms to
improve health facility and personal usage. While we can always improve, we think we have
done a lot to keep the "pain and disability" level as low as possible. In a small country where
we have an easier time to measure cause and effect than you do in the USA, we also see that
we are more quickly getting people off the "sickness income insurance system" and more
quickly back to being taxpayer than was the case earlier.

While rationing may permit the government to save on costs and thereby restrain health
care budgets, putting patients on waiting lists is not cost-free. One study that examined
over 1,400 Swedes on a waiting list for cataract surgery found that 5.2 million kronas
were spent on hospital stays and home health care for patients waiting for surgery. That
was the equivalent of what it would have cost to give 800 patients cataract surgery.
And these are just the type of studies that are widely reported in the Swedish mass media and
then put the pressure for reform squarely on the politicians and health professionals
involved. While very hard to compare, I think the Swedish general public is more informed
about weaknesses and shortfalls in their system, than are the Americans. Undoubtedly in
general, it seems any situation has to become much worse in the USA before change occurs
than here in Sweden. If I am right in that judgment, I suspect a lot has to do with political
accountability and market awareness.

While Sweden is a first world country, its health care system - at least in regards to
access - is closer to the third world. Because the health care system is heavily-funded
and operated by the government, the system is plagued with waiting lists for surgery.
Those waiting lists increase patients' anxiety, pain and risk of death.

I strongly disagree. We are not in the least plagued by surgery waiting lists. And everyone is
getting the surgery they for medical reasons, and no other, need and require. I have never
been able to understand American conservative thinking that all government financing is
"bad" and "inefficient." That attitude reflects only backward onto the citizenry/voting public
and other systems a country has in place. For me, a Swedish conservative, a pragmatic,
fiscally responsible, socially inclusive approach will always produce better results - with
government AND privately run systems -and a mix thereof.

When the United States chooses to reform its health care system, reform should lead to
improvement. Reforming along the lines of Sweden would only make our system worse.
Of the 45 million uninsured in the US- about 13 million uninsured are illegal immigrants
and another 13 million don't buy insurance because they are either young and healthy
or independently wealthy.

And the independently wealthy should not have to pay for just health care of others less able
to pay for it? And "illegal" immigrants who very often provide services, even pay taxes, etc to
the society should not have a basic , yes universal, human right? And the young and healthy
should not be covered, nor pay? Sorry, while I certainly respect your right to your views, I'm
not buying and am most happy living with the Swedish health care system. And I trust it will
be the majority of Americans that determine just how your health care system will be
reformed.

Regards,
Gail